Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Examining the Benefits of Massage Therapy For Survivors of Sexual and Domestic Violence by Audra Lynn Hixson ISBN: 1-58112- 315-9 DISSERTATION.COM Boca Raton, Florida USA • 2006 Examining the Benefits of Massage Therapy For Survivors of Sexual and Domestic Violence Copyright © 2005 Audra Lynn Hixson All rights reserved. Dissertation.com Boca Raton, Florida USA • 2006 ISBN: 1-58112- 315-9 Examining the Benefits of Massage Therapy for Survivors of Sexual and Domestic Violence by Audra Lynn Hixson A Dissertation Submitted to the faculty of Clayton College of Natural Health in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy i Examining the Benefits of Massage Therapy for Survivors of Sexual and Domestic Violence by Audra Lynn Hixson A Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Clayton College of Natural Health Birmingham, Alabama December, 2004 Approved by: ___________________________ Committee Chairperson _____________________ Date ___________________________ Committee Member _____________________ Date ___________________________ Committee Member ______________________ Date ii Abstract Women experience sexual and domestic violence at alarmingly high rates. Recovery from this type of trauma can be a complex and extensive process, that in best cases, involves a broad network for support. This dissertation examined the experiences of women over the age of 21 who have received massage therapy during their healing process from sexual or domestic violence. For the purposes of this study, the women who participated were often referred to as “survivors of abuse.” Current research examined in the literature review indicates that the effects of this type of trauma are multifaceted and that one of the interventions sought for diminishing the effects of this trauma is massage. The importance of this study, completed with the use of descriptive research methodology, included the opportunity to gain information from abuse survivors about their personal experiences with massage and how they can best be served by the massage therapist. The results of a self report survey and interview process provide valuable information to raise awareness of these societal issues among massage professionals. While the subjects were not interviewed about their specific experiences of abuse, they provided important information about the effects that these experiences have had on their lives. Further, the women interviewed shared information about the concerns that they had with regard to massage therapy and some of the specific experiences that they have had during massage sessions. Although the sample size was small, with 10 women interviewed, the information provided has clear implications for the practice of massage therapy. Some of the iii implications found involve therapist gender, trust building between client and practitioner, and communication with the client during massage therapy sessions. Recommendations for massage professionals have been made based on these findings. Further research opportunities exist in several areas and include screening massage clients for abuse during the intake process, examining the challenges for male massage therapists and female massage therapists, and evaluating the massage educational institutions for training in issues of trauma particular to sexual and domestic violence. iv Acknowledgements I would like to acknowledge my advisor at the Clayton College of Natural Health, Dr. Janice Martin for her positive support and guidance during this process. I appreciate the work of all the committee members who have reviewed this dissertation as well. Finally, thanks to my friends and family who have supported me during my education and this dissertation process. I am deeply grateful to all of the women who were brave enough to talk about their experiences of sexual and domestic violence with me in the hope of making the massage therapy experience more helpful for others. I am sorry that you have had these experiences, but feel honored to know you as survivors. You are resilient and courageous women and I extend to you each support and respect as you engage in your healing journey. v Table of Contents Title Page………………………………………………………………..i Acceptance Form………………………………………………………..ii Abstract………………………………………………………………….iii Acknowledgements……………………………………………………...v Tables……………………………………………………………………vii Chapter 1: Introduction………………………………………………......1 Chapter 2: Review of Literature ……………………………………….. 8 Chapter 3: Methodology…………………………………………………25 Chapter 4: Results………………………………………………………..32 Chapter 5: Discussion……………………………………………………50 Appendix A………………………………………………………………67 Appendix B………………………………………………………………68 Appendix C………………………………………………………………71 Appendix D………………………………………………………………72 References………………………………………………………………..73 vi List of Tables Table 1: I have had emotional problems since the abuse………………...34 Table 2: My physical health has been affected by the abuse…………….35 Table 3: I feel my overall wellness has been decreased since the abuse…36 Table 4: Massage therapy has been good for my emotional health………37 Table 5: Massage therapy has helped me heal from the abuse……………38 Table 6: I have been “triggered” or reminded of abuse during a massage session……………………………………………………………39 Table 7: I have felt safe and comfortable with the therapist during my massage sessions…………………………………………………40 vii CHAPTER 1: INTRODUCTION Statement of Problem Two of the most common forms of trauma in our society include sexual and domestic violence. While both women and men can be victims of these types of trauma, women experience sexual and domestic violence at alarmingly high rates. According to the Federal Bureau of Investigation, 6 million women are beaten by their partners each year in America and rape is a regular form of abuse in 50% of violent relationships (Mines, 2001b). The Pennsylvania Coalition Against Rape (2004) states that an estimated 1 out of every 4 girls will be sexually assaulted before the age of eighteen. Sexual abuse includes a variety of behaviors but is generally classified as any act of a sexual nature that “is forced on a person or which occurs as a result of coercion” (Alic, 2001, ¶1). It is important that coercion can include emotional, verbal or physical pressure to gain control of the victim. Specific acts of sexual abuse may include exposure of young children to sexual experience for gratification of an adult, rape, incest, exhibitionism, and verbal harassment (Alic, 2001). Domestic violence describes emotional, physical and verbal coercive acts that occur between family members or intimate partners. Among studies of women affected by domestic violence, “the most common forms of violence included pushing, grabbing, shoving, shouting, and threatening” (Walling, 2002, ¶ 2). Forced sexual activities, choking, punching, and other forms of violence also occur in these relationships (Walling, 2002). 1 Because sexual and domestic violence have historically been seen as personal and private problems rather than issues of social concern, a high comfort level does not exist among health care professionals when dealing with these issues (Laing, 2001). National organizations such as the Family Violence Prevention Fund have done an enormous amount of work in recent years through public awareness campaigns and health care provider specific trainings concerning appropriate screening, referral, and support of clients for issues of abuse. Researchers such as Stalker, Schachter, and Teram (1999) have completed a research study that interviewed women who have experienced abuse to offer suggestions for physical therapists when working with abuse survivors. Despite the fact that “more than one in five Americans report having had a massage from a massage therapist in the last five years”, massage therapists have yet to be included in a formal training process involving education or protocols for working with abuse survivors (Koutrouby, 2002, ¶2). Ms. Lisa Olcese, Director of Educational Services at a women’s shelter in Colorado states: What a tremendous service massage therapists and body workers provide to the world by giving people the opportunity to have a positive experience with their bodies. For survivors of domestic violence, this experience can be an important step toward healing from abuse. Safe touch and a consistent, confidential, supportive environment are critical components for positive social change. It takes a community to create a peaceful world, and bodywork is a necessary aspect of this vision (Mines, 2001b, ¶1). 2 Because survivors of abuse will be seen in the offices of massage therapists and massage therapy can play a critical role in their healing process, it is important to evaluate whether survivors are receiving the care and support they need from professional massage therapists. Background The effects of sexual and domestic violence on the individual can be seen physically, emotionally, and spiritually (Timms & Connors, 1990; Rothschild, 2000). In fact, the Population Information Program’s (2000) report: Ending Violence Against Women cites that there is a 50 to 95% probability that a woman will develop Post Traumatic Stress Disorder (PTSD) following a sexual assault. More specifically, this indicates that survivors of sexual and domestic violence often experience chronic anxiety, depression, physical muscle tension or pain, and insomnia among other issues (Bloom, 2000b). Recovery from this type of trauma can be a complex and extensive process that in best cases involves a broad network for support. This support includes not only psychotherapists and medical doctors, but also physical therapists, chiropractors and massage therapists (Stalker et. al, 1999). With so many people affected by these issues, it is likely that there are many people who could benefit from services that attend to the effects of abuse for themselves or for their loved ones. Without support and an open environment surrounding these topics, these individuals may not know where to turn for those interventions. If the helping professionals who are capable of making a difference in 3 the trauma symptoms are not comfortable with issues of sexual and domestic violence, then that support may not be easily discovered. Chronic pain is another common form of disability seen in women who have survived sexual or domestic violence (Kendall-Tackett, Marshall, & Ness, 2003). One of the common types of healing modality sought for chronic pain and tension is massage therapy (Koutrouby, 2002). “Therapeutic massage is the manipulation of the soft tissue of the whole body areas to bring about generalized improvements in health, such as relaxation or improved sleep, or specific physical benefits, such as relief of muscular aches and pains” (Vickers & Zollman, 1999, p.1254). Besides these more concrete benefits of massage therapy, there is also potential benefit for individuals to receive safe and compassionate physical contact in a comfortable environment when receiving treatment from a professional massage therapist (Mines, 2001b). Due to the prevalence of sexual and domestic violence and the intimate nature of massage sessions, it is crucial for the massage therapist to be well informed about the issues of sexual and domestic violence and be educated about working with trauma survivors as massage clients. When talking generally about the relationship between the massage practitioner and client, Collinge (1996, p.11) states, “Normal boundaries of social interaction are crossed. Hence there is a special need for sensitivity and regard for the client on the part of the practitioner that matches and perhaps even exceeds that of many doctor-patient relationships.” This is especially true with survivors of abuse who may be hyper vigilant about becoming vulnerable to another person through physical contact and intimacy. 4 Hypothesis and Research Questions A well trained massage therapist has the potential to be an ally in the fight against sexual and domestic violence as well as an effective partner in the healing process of individual abuse survivors. In researching the issue of a massage therapist’s need for education regarding sexual and domestic violence, we must evaluate what role the massage therapist can play in working to combat the effects of sexual and domestic violence on the individual. It is also important to evaluate how this trauma affects a massage therapist’s work with a client. More specifically, what are the most common issues for women following the experience of being a victim of sexual and domestic violence? And, what do they do in order try and heal from these effects? For survivors who have massage therapy, what have been their experiences and what were the challenges, if any, associated with the massage experience? Lastly, do massage consumers who have experienced abuse have any suggestions for improving the profession with regard to services for this population? It is likely that being sexually assaulted or experiencing domestic violence will create challenges for a women who engages in massage therapy and also the therapist she is working with. Unless a massage therapist has been trained in the effects of sexual and domestic violence and practices in a sensitive manner, the benefits of the massage will decrease for some massage clients. With the frequency of 5 abuse in our society, massage training programs would benefit from including training on these issues in the curriculum they provide for students. Professional massage associations should also be interested in this aspect of a certified massage therapist’s education. Significance of Study The importance of this study includes the opportunity to gather information from sexual and domestic violence survivors about how they have been affected by the trauma they have experienced. Survivors can best provide information regarding how they can be served by the healing art of massage therapy. The information gained in this research serves as a tool to raise general awareness about the issues of sexual and domestic violence in our society. The results of this research also provide a valuable resource for the professional massage therapist and those who educate massage students by providing information about the quality of massage therapy experienced by this population of massage consumers. Lastly, the information contained within this study has the potential to serve as evidence that these issues should be incorporated into massage therapist training programs and that training on the issues of sexual and domestic violence should be required by the associations that govern the practice of massage therapy as part of the required continuing education process for certification. Summary 6 Sexual and domestic violence are two forms of trauma that commonly directly affect the lives of women. Because these types of trauma are seen as personal issues by many helping professionals in our society, many are not open to asking their clients about these issues or comfortable talking with survivors about their experiences when they are disclosed. As a result, there is a lack of helping professionals who are educated about the best ways to help the survivors of abuse they may see everyday. For those professionals who do engage in working with survivors of abuse, the multidimensional nature of this trauma can present challenges. This contributes to isolation of the survivor of abuse and may cause her to suffer in silence rather than seek support. With focus on the effects of trauma has come the knowledge that sexual and domestic violence can have lasting physical and emotional effects on the survivor. As survivors try to navigate the healing journey, one of the professionals they may employ is a massage therapist. Because of the intimate nature of massage therapy, there are many possible implications for a survivor seeking these services. The purpose of this study was to examine the experiences that survivors of these types of abuse have had with massage therapy and to describe these interactions with the intent of making suggestions for the education and practice of massage therapists. 7 CHAPTER 2: REVIEW OF LITERATURE Effects of Sexual and Domestic Violence Violence against women through sexual, physical and emotional abuse is a “significant health problem and is believed by many to have reached epidemic proportions in the United States today” (Hastings, 2003, ¶1). Current research studies on the effects of sexual and domestic violence provide information on the aftermath of abuse and how the effects of these types of trauma persist if not resolved on an emotional, physical and spiritual level. Experts suggest that because our society denies the magnitude of sexual and domestic violence and often blames the victim of these types of crimes, many survivors of abuse do not get the emotional support that they need to grieve and heal following abuse. The issue of grieving is an important concept for those who have survived the experience of violence from another person. While it is commonly expected and accepted that a person may grieve the death or loss of a loved one, the personal losses associated with this type of victimization occur without support as “the expression of grief for these losses is unaccepted, rejected, denied and stigmatized” (Bloom, 2000a, p. 408). The impact of this societal ignorance is seen when the effects of abuse are repressed or magnified and the long term effects of trauma are then manifested in the individual (Bloom, 2000a). Another misconception noted in current literature regarding sexual and domestic violence is that the effects of emotional or verbal abuse are somehow less than physical or sexual assault. It is important to acknowledge that the effects of emotional trauma can be just as disruptive to an individual as other types of physical trauma. As Rothschild (2000, p. 5) states, “Trauma is a psychophysical experience, 8 even when the traumatic event causes no bodily harm.” Anthony Deavin (2002, ¶2) notes that “trauma, especially emotional trauma, may be locked within the tissues of the body, disturbing or blocking energy flow, with ill health as the result.” Particularly for survivors of abuse, “somatization may represent not only the effects of prolonged stress but also the long term effects of suppressed grief on the body” (Bloom, 2000a, p.410). As Steinberg, Pineles, Gardner, and Mineka (2003) found in their study of 29 previously abused women living in a domestic violence shelter, even the loss of social roles outside of the home due to isolation by the abusive partner can impact the victim on many levels. Studies of trauma survivors report that repressed emotional pain emerges as mental, emotional, and physical disease (Mines, 2001a; Carlson & Dalenberg, 2000). Research has shown that survivors of abuse are also at greater risk for alcoholism, drug abuse, and suicidal urges (Grinage, 2003). These problems frequently arise out of attempts to avoid or diminish the emotional difficulties following abuse (Bloom, 2000b). Issues specific to repressed emotional pain and trauma in abuse survivors include dissociation, a decrease in body awareness, depression, anxiety, compulsive self injury behaviors, chronic pain and physical disability as a manifestation of psychological stress (Ashley, 2003; Meagher, 2004). Post Traumatic Stress Disorder (PTSD) is a specific label given to describe this complex group of symptoms that a person may experience following unresolved trauma. A traumatic event is defined in the DSM-IV as one that involves an “actual or threatened death or serious injury or threat to the physical integrity of self or others” (Carlson & Dalenberg, 2000, p.5). While these types of events do cause a 9 response that is intense enough to generate a trauma response in some individuals, there is more recent research that indicates traumatic stressors that do not necessarily involve serious physical injury or death can still produce the symptoms of PTSD in some individuals (Dalenberg, 2000). Further evidence of this issue is reported by Martin (2004, ¶1) when he states, “Once thought to be experienced primarily by war veterans, PTSD is now known to occur in survivors of sexual, physical, or emotional abuse, and in persons who have witnessed a traumatic event.” With this knowledge, it may be more easily seen why survivors of a variety of experiences along the continuum of sexual and domestic violence may develop PTSD symptoms. It is important to understand that “a diagnosis of PTSD does not indicate personal weakness or mental illness” (Martin, 2004, p.2). In their study of PTSD, Hidalgo and Davidson found that “the most common traumatic events associated with PTSD in women are rape and sexual molestation” (Grinage, 2003). The impact of PTSD as an anxiety disorder has been the focus of study in a variety of health related disciplines. PTSD has been seen as a complex disorder and one that “has a neurological basis and crosses physical, emotional, and spiritual boundaries” (Fitch & Dryden, 2000). A diagnosis of PTSD is usually made when symptoms that disrupt normal life activities persist for more than one month (Grinage, 2003). Experts such as Martin (2004) explain the difference between individual experiences with PTSD by relating the depth of symptoms to: 10 the severity of the event, the person’s personality and genetic make-up, and by whether the trauma was expected … lastly, the nature of the trauma itself is a factor; as a rule, traumas resulting from intentional human behavior (rape, torture, genocide, domestic violence, etc.) are experienced as more stressful than traumas resulting from accidents, natural disasters, or animal attacks. (p. 1) Just as the effects of sexual and domestic violence can persist for months or years following abuse, PTSD resulting from the trauma can have an immediate or delayed onset and persist untreated for years (Martin, 2004; Alic, 2001). Some of the many diagnostic signs and symptoms that have been seen by researchers in observing someone with PTSD include insomnia, hyper vigilance about safety, emotional unresponsiveness, repeated dreams or intrusive thoughts, overwhelming feelings and mood swings, fibromyalgia, physical pain, and avoidance of perceived reminders of the trauma (Martin, 2004; Fitch & Dryden, 2000). Current research shows that individuals with PTSD are more apt to use a variety of health care resources than the general public and are often seen by physicians as “difficult” patients to work with due to the variety of persistent complaints they present (Hastings, 2003; Grinage, 2003). Combining Bloom’s research that notes the low comfort level of our society regarding the issues of sexual and domestic with O’Dowd’s reflection of a physicians view of PTSD patients “who evoke an overwhelming mixture of exasperation, defeat, and sometimes plain dislike” (Grinage, 2003, ¶ 2), there is a potential for research to focus on whether survivors of abuse who turn to the traditional medical community are getting the care and support that they need. 11 In addition to the potential short term and chronic symptoms of trauma mentioned as part of PTSD, experts report that a survivor of abuse will often experience the loss of a sense of “safety and security in the world” (Van Wormer, 2001; Fitch & Dryden, 2000). In relation to this loss of a sense of general safety, Bloom (2000b) discusses the challenges of those survivors who are then in a “chronic state of physiological hyper arousal” and who manage this experience with a survival skill known as dissociation. Survivors who dissociate may display a change in their level of consciousness and although this defense mechanism helps to manage the overwhelming effects of being constantly over stimulated, it has negative effects as well. When looking at adult survivors of childhood abuse, Bloom (2000b) suggests: But the price they pay for this protection is substantial – memories, feelings, identity are fragmented. This sense of an integrated self is something that adults raised in functional families simply take for granted and is truly known only in its absence. (p. 471) Interventions for Trauma To date, the majority of mainstream medical literature surrounding work with persons experiencing the symptoms of PTSD looks at the efficacy of psychotherapy, psychiatric evaluation or medication usage. While there is a mention of the necessity for a “multidimensional approach” when working with survivors of trauma, this approach is described by Grinage (2003) as one that involves patient education, support groups, psychotherapy and the use of medication to alleviate symptoms of anxiety or depression. Martin (2004) discusses the concept of a treatment team for 12 proper care of a an individual suffering from PTSD and the “team leaders may include psychiatrists, psychologists, nursing staff, behavior specialists and other medical/behavioral staff” (p.3). Research shows that it is common for survivors of abuse and people who are affected by PTSD for other reasons to turn to mainstream medical professionals for care following trauma. It is also common for survivors of abuse to engage in talk oriented counseling or psychotherapy in an attempt to process their experiences and receive support from a trained professional. Martin (2004) reports that cognitivebehavioral therapy involving relaxation training combined with medication appears to be the “most helpful” treatment of PTSD. While this type of healing modality is beneficial in allowing the survivor to process experiences and gain intellectual and emotional awareness in a supportive environment, research with survivors of trauma show that talking and medication alone may not be sufficient to deal with the many layers of trauma affecting the body and soul of the individual (Bloom, 2000c). While survivors of abuse may utilize many of the same interventions that others affected by PTSD will, survivors may have more complex symptoms that include the effects of physical trauma and in some cases, repeated injury. One of the most important aspects of providing interventions for survivors of abuse is correctly identifying the reason for their symptoms and determining whether the abuse is ongoing or in the past (Bloom, 2000c). “Few studies have taken into account the cumulative effect of multiple victimizations … on health care service use” (Hastings, 2003, ¶ 4). 13 Research has been done to examine the connection between chronic general health complaints, gynecologic symptoms, and gastrointestinal diseases (Hastings, 2003). Because survivors of abuse experience such a wide variety of ailments following the trauma and present in a multitude of ways for medial treatment, current researchers such as Hastings and Laing stress the importance of screening all patients for abuse. When a patient is not screened for abuse, complications can develop in the treatment plan. As an example of this, Bloom (2000c) states that: Chronic somatic complaints often accompanied by the overuse or abuse of prescription pain medications is common. When physical symptoms are a manifestation of unresolved grief, the pattern may be one of…drug seeking while the person and their health care providers seek a physical solution to a nonphysical problem. The result is bound to be an increasing level of frustration, chronicity, and compounded rage on the part of everyone involved. (p. 517) According to Walling (2002, p. 1), “Surveys from several countries report that 5 to 20 percent of women attending primary care practices have experienced domestic violence, but few have discussed the problem with their physician.” Studies conducted in Ireland, England and America, including those by Bradley and Associates and Richardson, have all produced data that reveals 39 to 41 percent of the women randomly surveyed in the waiting room of a primary care physicians office had experienced physical violence by a recent partner (Walling, 2002). Of these same women surveyed, 4 to 5 % reported that they had ever been asked about abuse by their physician (Walling, 2002). 14 Integrative trauma therapy, which has not received as much attention by researchers, is a multidimensional approach that encompasses techniques designed to address the mental, emotional and also physical levels of the body. Trauma experts now state that it is important to remember the mind-body connection in all interventions with survivors of abuse (Rothschild, 2000). With increased literature describing research into the effects of trauma, most therapists also currently acknowledge that PTSD is not just a psychological condition, but one that also has physical and spiritual components (Rothschild, 2000). Complementary and alternative medicine, which features a variety of healing modalities that focus on the whole person rather than just treating individual symptoms, has recently received more attention through scientific research. “Within the past 5 years, several studies have pointed to the widespread use of complementary and alternative medicine in the United States” (Palinkas & Kabongo, 2000, p.1). “With a growing use by consumers, referrals for alternative therapies are now also coming from primary care physicians, insurance companies, and self-referrals” (Becker, 2003, p.70). Despite growth in awareness about these healing modalities and the increase in the number of people who are turning to complementary practitioners to improve their health, there has not been significant research into the specific reasons individuals are seeking alternative services or the benefits that are reported. Within the field of complementary healing, research has been directed toward working with the effects of trauma in the body and toward the issues of how best to work with survivors of sexual and domestic violence. As a result “the Oriental Medicine Association of New Mexico has passed a resolution supporting the training 15 of practitioners in clinical management of domestic violence” (Laing, 2001, p.4) in order to screen and appropriately serve acupuncture clients who may be dealing with domestic violence. Yoga instructors are being educated about the possibility of emotional release among class participants who have previously experienced trauma and through the spiritual and physical practice of yoga “break through places in the subtle body that are blocked with unresolved issues and energy” (Raskin, 2004, ¶5). A recent meeting of healers in Mexico combined psychologists, occupational therapists, social workers, movement therapists and massage therapists among others to learn from each other and develop integrative approaches to working with survivors of trauma (Mines, 2001a). Martin (2004) suggests that people suffering from PTSD may benefit from complementary approaches that include: meditation, yoga and massage therapy. Due to the increased publication of literature about alternative modalities of healing and the multidimensional nature of many of the effects of trauma, it is not surprising that survivors of sexual and domestic violence might eventually turn to complementary healing modalities including some form of massage or bodywork as an adjunct to the healing process. While some individuals may not relate the symptoms that cause them to seek massage therapy to be results of past or present abuse, the intimate nature of massage can cause emotions and trust issues to surface during treatment (Mines, 2001; Ashley, 2003). Current literature on bodywork shows that various forms of bodywork, such as Trauma Touch Therapy and the Rosen Method have been developed as specific approaches toward working with clients affected by trauma (Mowen, 2001; Gustin, 16